Case2

							Case 2. 16 year old Gabe discharged from residential treatment to a foster home, with one
month supply of medications (Risperdal and Adderall XR); diagnoses include: adjustment
disorder, ADHD; does not have any mental health follow-up. Was failing school when
entered residential but did better as year wore on. Behind educationally—at 9th grade
level.

History per Gabe: Minimal, doesn’t want to be here.
History per foster mother: Not yet in school as needs health form completed. Has been in
home for a week and spends most of time in his room. When in rest of home,” has his
music in his ears”. Foster mother has meds in a plastic bag in case we wanted to see them.

Now What?

Approaches with the Recalcitrant Teen:
A very specific compliment. Or something that is probably close to accurate.
“I am sure you don’t want to be here today.”
“I see a lot of teen-agers who have been through a lot in their lives, usually through no fault
of their own.”
“ I know you probably don’t feel like talking with me, but I would like to see if there is any
way in which I can be helpful to you today.”
“That’s a lot of medicine. Can you help me understand whether some or all of these are
helping you—or not.”

History per Gabe:
Thinks he is in care because his family could not handle his behaviors. He was truant from
school or suspended a lot and got arrested once for stealing something. They didn’t like his
friends who were mostly into drugs and not going to school. He has been on Adderall XR
for years, and before that some other medicines to help his inattention and hyperactivity.
School is boring for him. The Risperdal was to help him with his anger problems. He used
to hit other kids or adults when he got angry. He is still angry but doesn’t get so upset
anymore. He does admit to feeling sad a lot, not having any fun. He sleeps a lot. He has
gained some weight on the Risperdal but he used to have trouble gaining weight on the
Adderall XR. So overall he is happy with his weight gain.
Before foster care he lived with his mom and a succession of her boyfriends. He lived with
his dad, a known alcoholic, briefly but left after a bad physical fight. The person in his
family he feels most attached to is his maternal grandmother and he is worried because she
is getting older and has some health problems.
He has two older siblings, one of whom is in jail. His sister is pregnant and he does not like
her boyfriend.
“My mom, she is crazy man.”
Foster home: “alright” “I stay to myself.”
Future plans: shrugs.

What are we going to do?

Vital signs, growth, Physical Examination: Normal
Trauma screen: ACE: neglect, exposure to DV, parents split up, physical abuse, emotional
abuse, maternal MH issues, father an alcoholic. >4.
Gabe did agree to fill out a Child Behavior Checklist. You learn that he likes basketball
and video games and likes to work with his hands. He views himself as kind, helpful and
cooperative except when he gets upset. He worries a lot about his family, himself and his
future. He has a good sense of humor. He scores in the clinical range on Internalizing and
Externalizing symptoms and total problems. He has no activities, no real friends and
scores below average on social skills and activities.

Mental Health Referral. Discuss that can refill meds but probably needs to see a real
mental health person to help determine when can come off medications. He reluctantly
agrees. Does he need trauma-focused CBT, Interpersonal therapy for Adolescent?

Medications: Refill for now, have him return in a month. Does he need an anti-
depressant?

Labwork: needs because he is new to care and is on Risperdal.

Visitation: None. He does not want to visit his parents. Might be interested in seeing his
sister.

Discussion with caseworker:
Normalizing activities, visitation with sister, mental health referral. Learning evaluation.